MANAGEMENT OF

ALLERGIC RHINITIS
AND ITS IMPACT ON
ASTHMA
POCKET GUIDE
MANAGEMENT OF
ALLERGIC RHINITIS
AND ITS IMPACT ON
ASTHMA
BASED ON THE ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA WORKSHOP REPORT
In collaboration with the World Health Organisation
A Pocket G ui d e for Physi ci a ns a nd N urses
2 0 0 1
T
M
ARIA
ALLERGIC RHINITIS AND ITS IMPACT
ON ASTHMA INITIATIVE
MEMBERS OF THE WORKSHOP EXPERT PANEL
Nadia At-Khaled
Isabella Annesi-Maesano
Claus Bachert
Carlos Baena-Cagnani
Eric Bateman
Sergio Bonini
Giorgio Walter Canonica
Kai-Hkon Carlsen
Pascal Demoly
Stephen R. Durham
Donald Enarson
Wytske J. Fokkens
Roy Gerth van Wijk
Peter Howarth
Nathalia A. Ivanova
James P. Kemp
Jean-Michel Klossek
Richard F. Lockey
Valerie Lund
Ian MacKay
Hans-Jrgen Malling
Eli O. Meltzer
Niels Mygind
Minoru Okuda
Ruby Pawankar
David Price
Glenis K. Scadding
F. Estelle R. Simons
Andrzej Szczeklik
Erkka Valovirta
Antonio M. Vignola
De-Yun Wang
John O. Warner
Kevin B. Weiss
Jean Bousquet, Chair
Paul van Cauwenberge, Co-Chair
Nikolai Khaltaev
2
TABLE OF CONTENTS
PREFACE ..................................................................................................3
RECOMMENDATIONS..............................................................................4
DEFINITION AND CLASSIFICATION ........................................................5
TRIGGERS OF ALLERGIC RHINITIS..........................................................6
MECHANISMS OF ALLERGIC RHINITIS ..................................................7
CO-MORBIDITIES ....................................................................................8
Asthma ............................................................................................8
Others..............................................................................................8
SYMPTOMS OF ALLERGIC RHINITIS ......................................................9
DIAGNOSING ALLERGIC RHINITIS ......................................................10
MANAGEMENT......................................................................................11
Recommendations are evidence-based ..............................................12
SELECT MEDICATIONS ..........................................................................13
Pharmacological treatment ..............................................................14
Glossary of medications ..................................................................15
CONSIDER IMMUNOTHERAPY ............................................................17
TREAT IN A STEPWISE APPROACH (ADOLESCENTS AND ADULTS) ......18
TREATMENT OF CONCOMITANT RHINITIS AND ASTHMA..................19
PAEDIATRIC ASPECTS............................................................................20
SPECIAL CONSIDERATIONS..................................................................21
Pregnancy......................................................................................21
Ageing ..........................................................................................21
ADAPTING GUIDELINES FOR DEVELOPING COUNTRIES....................22
ADAPTING GUIDELINES FOR LOCAL USE............................................23
3
PREFACE
Allergic rhinitis is cli ni cally def i ned as a symptomatic disorder of the nose,
induced after allergen exposure, by an IgE-mediated inflammation of the
nasal membranes.
Allergic rhinitis represents a global health pr oblem. It is a common disease
worldwide affecting at least 10 to 25 % of the population and its prevalence
is increasing. Although allergic rhinitis is not usually a severe disease, it alters
the social life of patients and affects school performance and work productivity.
Moreover, the costs incurred by rhinitis are substantial.
Asthma and r hi ni ti s are common co-morbidities, suggesting the concept of
"one airway, one disease".
New knowledge about the mechanisms underlying allergic inflammation
of the airways has resulted in better therapeutic strategies. New routes of
administration, dosages, and schedules have also been studied and validated.
Guidelines for the diagnosis and treatment of allergic rhinitis have already
been published. However, they have not been evidence-based with a formal
assessment of the evidence for recommendations, and have not considered the
recommendations in terms of patient co-morbidities.
The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative has been
developed in collaboration with the World Health Organisation (WHO).
This document is intended to be a state-of-the-art pocket guide for the specialist
as well as for the general practitioner. It aims:
to update clinicians knowledge of allergic rhinitis
to highlight the impact of allergic rhinitis on asthma
to provide an evidence-based approach to diagnosis
to provide an evidence-based approach to treatment
to provide a stepwise approach to the management of the disease.
4 RECOMMENDATIONS
RECOMMENDATIONS
1. Classification of allergic rhinitis as a major chronic respiratory disease
due to its:
prevalence
impact on quality of life
impact on work/ school performance and productivity
economic burden
links with asthma
association with sinusitis and other co-morbidities such as conjunctivitis.
2. Along with other known risk factors, allergic rhinitis should be considered
as a risk factor for asthma.
3. A new subdivision of allergic rhinitis has been made:
intermittent
persistent
4. The severity of allergic rhinitis is classified as "mild" or "moderate/ severe"
depending on the severity of symptoms and quality of life outcomes.
5. Depending on the subdivision and severity of allergic rhinitis, a stepwise
therapeutic approach is outlined.
6. The treatment of allergic rhinitis should combine:
allergen avoidance (when possible)
pharmacotherapy
immunotherapy
7. Environmental and social factors should be optimised to allow the patient to
lead a normal life.
8. Patients with persistent allergic rhinitis should be evaluated for asthma by
history, by chest examination, and if possible, by the assessment of airflow
obstruction before and after a bronchodilator.
9. Patients with asthma should be appropriately evaluated (history and physical
examination) for rhinitis.
10. A combined strategy should ideally be used to treat coexistant upper and
lower airway diseases in terms of efficacy and safety.
11. In developing countries, a specific strategy may be needed depending on
available treatments and interventions, and their cost.
CLASSIFICATION OF
ALLERGIC RHINITIS
Aller gi c r hi ni ti s is clinically defined as a symptomatic disorder of the nose
induced by an IgE-mediated inflammation after allergen exposure of the
membranes of the nose.
Symptoms of allergic rhinitis include:
rhinorrhea
nasal obstruction
nasal itching
sneezing
which are reversible spontaneously or with treatment.
Allergic rhinitis was previously subdivided, based on time of exposure, into
seasonal, perennial, and occupational. This subdivision is not entirely
satisfactory.
The new classification of allergic rhinitis:
uses symptoms and quality of life parameters
is based on duration, and is subdivided into "intermittent" or "persistent"
disease
is based on severity, and is subdivided into "mild" or "moderate-severe",
depending on symptoms and quality of life
Figure 1: Classification of allergic rhinitis
RECOMMENDATIONS 5
Intermittent
symptoms
<4 days per week
or <4 weeks
Mild
normal sleep
normal daily activities,
sport, leisure
normal work and school
no troublesome
symptoms
Moderate-Severe
one or more i tems
abnormal sleep
impairment of daily
activites, sport, leisure
problems caused at work
or school
troublesome symptoms
Persistent
symptoms
>4 days/ week
and >4 weeks
TRIGGERS OF ALLERGIC RHINITIS
Allergens
Aer oaller gens are often involved in allergic rhinitis.
The increase in domestic allergens is partly responsible for the increase in
the prevalence of rhinitis, asthma, and allergies.
The allergens present in the home are principally mites, domestic animals,
insects or are derived from plant origin.
Common outdoor allergens include pollens and moulds.
Occupati onal r hi ni ti s is less well documented than occupational asthma, but
nasal and bronchial symptoms often co-exist in the same patient.
Latex aller gy has become an increasing concern to patients and health
professionals. Health professionals should be aware of this problem and
develop strategies for treatment and prevention.
Pollutants
Epidemiological evidence suggests that pollutants exacerbate rhinitis.
The mechanisms by which pollutants cause or exacerbate rhinitis are now
better understood.
Indoor ai r polluti on is of great importance since subjects in industrialised
countries spend over 80% of their time indoors. Indoor pollution includes
domestic allergens and indoor gas pollutants, among which tobacco smoke
is the major source.
In many countries, ur ban-type polluti on is primarily of automobile origin
and the principal atmospheric pollutants include ozone, oxides of nitrogen
and sulphur dioxide. These may be involved in the aggravation of nasal
symptoms in patients with either allergic rhinitis, or, in non-allergic
subjects.
Diesel exhaust may enhance the formation of IgE and allergic inflammation.
Aspirin
Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) commonly
induce rhinitis and asthma.
6 CLASSIFICATION OF ALLERGIC RHINITIS
MECHANISMS OF
ALLERGIC RHINITIS
Allergy is classically considered to result from an IgE-mediated response
associated with nasal inflammation.
Allergic rhinitis is characterised by an inflammatory infiltrate made up of
different cells. This cellular response includes:
chemotaxis, selective recruitment and trans-endothelial migration of cells
release of cytokines and chemokines
activation and differentiation of various cell types including eosinophils,
T-cells, mast cells and epithelial cells
prolongation of their survival
release of mediators by these activated cells. Among these, histamine and
cysteinyl-leukotrienes (CystLT) are the major mediators
communication with the immune system and the bone marrow
Non-specific nasal hyperreactivity is an important feature of allergic rhinitis.
It is defined as an increased nasal response to normal stimuli resulting in
sneezing, nasal congestion and/ or secretion.
Intermittent rhinitis can be mimicked by nasal challenge with pollen allergens
and it has been shown that an inflammatory response occurs during the
late-phase reaction.
In persistent allergic rhinitis, allergic triggers interact with an ongoing
inflammatory reaction. Symptoms are due to this complex interaction.
"Minimal persistent inflammation" is a new and important concept. In patients
with persistent allergic rhinitis, allergen exposure varies throughout the year
and there are periods in which there is little exposure. Even though symptom
free, these patients, still present with inflammation of the nose.
The understanding of the mechanisms of disease generation provides a
framework for rational therapy in this disorder based on the complex
inflammatory reaction rather than on the symptoms alone.
7 MECHANISMS OF ALLERGIC RHINITIS 7
CO-MORBIDITIES
Allergic inflammation does not limit itself to the nasal airway. Multiple
co-morbidities have been associated with rhinitis.
Asthma
The nasal and bronchial mucosa have many similarities.
Epidemiological studies have consistently shown that asthma and rhinitis
often co-exist in the same patients.
Most patients with allergic and non-allergic asthma have rhinitis
Many patients with rhinitis have asthma
Allergic rhinitis is associated with and also constitutes a risk
factor for asthma
Many patients with allergic rhinitis have increased non-specific
bronchial hyperreactivity
Pathophysiological studies suggest that a strong relationship exists
between rhinitis and asthma. Although differences exist between rhinitis
and asthma, upper and lower airways are considered to be affected by
a common, and probably, evolving inflammatory process, which may be
sustained and amplified by interconnected mechanisms.
Allergic diseases may be systemic. Bronchial challenge leads to nasal
inflammation and nasal challenge leads to bronchial inflammation.
When considering a diagnosis of rhinitis or asthma, an evaluation of
both the lower and upper airways should be made.
Other co-morbidities
These include sinusitis and conjunctivitis.
The associations between allergic rhinitis, nasal polyposis and otitis
media are less well understood.
8 CO-MORBIDITIES
SYMPTOMS OF
ALLERGIC RHINITIS
Clinical history is essential for an accurate diagnosis of rhinitis, assessment of
its severity, and likely response to treatment.
In patients with mild intermittent allergic rhinitis, a nasal examination is
optimal. All patients with persistent allergic rhinitis need a nasal examination.
Anterior rhinoscopy, using a speculum and mirror, gives limited information.
Nasal endoscopy, usually performed by specialists, is more useful.
SYMPTOMS OF ALLERGIC RHINITIS 9
History
-nasal discharge
-blockage
-sneeze/ itch
2 or more
symptoms for >1 hr
on most days
sneezers and runners
Lund, V. J., et al., International Consensus Report on the Diagnosis and
Management of Rhinitis. International Rhinitis Management Working Group.
A llerg y, 1994; 49 (Suppl 19): 1-34.
blockers
sneezing especially paroxysmal little or none
rhinorrhea watery thick mucus
anterior and posterior more posterior
itching yes no
nasal blockage variable often severe
diurnal rhythm worse during day constant, day
improving at night and night,may
be worse at
night
conjunctivitis often present
Figure 2: Clinical assessment and classification
of rhinitis
DIAGNOSING
ALLERGIC RHINITIS
The diagnosis of allergic rhinitis is based on:
a typical history of allergic symptoms
allergic symptoms are those of sneezers and runners. However, these
symptoms are not necessarily of allergic origin
diagnostic tests
- In vi vo and i n vi tro tests used to diagnose allergic diseases are directed
towards the detection of free or cell-bound IgE. The diagnosis of allergy has
been improved by allergen standardisation providing satisfactory diagnos-
tic vaccines for most inhalant allergens.
- Immedi ate hyper sensi ti vi ty ski n tests are widely used to demonstrate an
IgE-mediated allergic reaction. These represent a major diagnostic tool in
the field of allergy. If properly performed, they yield useful confirmatory
evidence for the diagnosis of a specific allergy. As there are many
complexities for their performance and interpretation, it is recommended
that they should be carried out by trained health professionals.
- The measur ement of aller gen-speci f i c IgE in serum is of importance and is
of similar value to skin tests.
- Nasal challenge tests with allergens are used in research and, to a lesser
extent, in clinical practice. They may be useful, especially in the diagnosis
of occupational rhinitis.
Imagi ng is not usually necessary.
The diagnosis of asthma
Due to the transient nature of the disease, and the reversibility of the
airflow obstruction (spontaneously or with treatment) the di agnosi s of
concomi tant asthma may be difficult.
Guidelines for recognising and diagnosing asthma have been published by
the Global Initiative for Asthma (GINA) and are recommended by ARIA.
Measurement of lung function and confirmation of the reversibility of
airflow obstruction are essential steps in the diagnosis of asthma.
10 DIAGNOSING ALLERGIC RHINITIS
MANAGEMENT
The nasal and bronchial mucosa have many similarities.
The management of allergic rhinitis includes:
aller gen avoi dance:
- most allergen avoidance studies have dealt with asthma symptoms and
very few have studied rhinitis symptoms. A single intervention may be
insufficient to control symptoms of rhinitis or asthma
- however, allergen avoidance, including house mites, should be an integral
part of a management strategy
- more data are needed to fully appreciate the value of allergen avoidance
medi cati ons (phar macologi cal tr eatment)
speci f i c i mmunother apy
educati on
sur ger y may be used as an adjunctive intervention in a few highly
selected patients
These recommendations provide a strategy that combines the treatment of
both upper and lower airway disease in terms of efficacy and safety.
Follow-up is required in patients with persistent rhinitis and severe
intermittent rhinitis.
Figure 3: Therapeutic considerations
pharmacotherapy
safety
effectiveness
easy to be administered
patients
education
always indicated
immunotherapy
effectiveness specialist
prescription may alter
the natural course of
the disease
allergen
avoidance
indicated when
possible
MANAGEMENT 11
allergen
avoidance
indicated when
possible
patient
education
always indicated
immunotherapy
effectiveness
specialist prescription
may alter the natural
course of the disease
pharmacotherapy
safety
effectiveness
easy administration
COSTS
12 RECOMMENDATIONS ARE EVIDENCE-BASED
RECOMMENDATIONS
ARE EVIDENCE-BASED
Recommendations are evidence-based
Based on randomised-controlled trials (RCT) carried out on studies
performed with the previous classification of rhinitis:
seasonal (SAR)
and perennial (PAR) allergic rhinitis
The strength of recommendation is:
A: recommendation based on RCT or meta-analysis
D: recommendation based on the clinical experience of experts
SIT: specific immunotherapy
For sublingual and nasal SIT, the recommendation is only for very high dose
treatment
Intervention Seasonal Perennial
adults children adults children
oral H1-antihistamines A A A A
intranasal H1-antihistamines A A A A
intranasal corticosteroids A A A A
intranasal chromones A A A
anti-leukotrienes A
subcutaneous SIT A A A A
sublingual SIT A A A
nasal SIT A A A
allergen avoidance D D D D
13 SELECT MEDICATIONS 13
SELECT MEDICATIONS
Medications have no long-lasting effect following discontinuation. Therefore,
in persistent disease, maintenance treatment is required.
Tachyphylaxis does not usually occur with prolonged treatment.
Medications used for rhinitis are most commonly administered either
intranasally or orally.
Some studies have compared the relative efficacy of these medications, of
which, intranasal corticosteroids are the most effective. However, the choice
of treatment also depends on many other criteria.
The use of alternative therapy (e.g. homeopathy, herbalism, acupuncture) for
the treatment of rhinitis is increasing. There is an urgent need for large,
randomised and controlled clinical trials for alternative therapies of allergic
diseases and rhinitis. Scientific and clinical evidence are lacking for these
therapies.
Intramuscular injection of glucocorticosteroids is not usually recommended due
to the possible occurrence of systemic side effects.
Intranasal injection of glucocorticosteroids is not usually recommended due to
the possible occurrence of severe side effects.
PHARMACOLOGICAL
MANAGEMENT OF
ALLERGIC RHINITIS
Adapted from van Cauwenberge, P., et al., Consensus statement on the treatment of
allergic rhinitis. European Academy of Allergology and Clinical Immunology. A llerg y, 2000;
55(2): p.116-34.
14 SELECT MEDICATIONS
sneezi ng r hi nor r hea nasal nasal eye
obstr ucti on i tch symptoms
H1-antihistamines
oral ++ ++ + +++ ++
intranasal ++ ++ + ++ 0
intraocular 0 0 0 0 +++
Corticosteroids
intranasal +++ +++ +++ ++ ++
Chromones
intranasal + + + + 0
intraocular 0 0 0 0 ++
Decongestants
intranasal 0 0 ++++ 0 0
oral 0 0 + 0 0
Anti-cholinergics 0 ++ 0 0 0
Anti-leukotrienes 0 + ++ 0 ++
Effect of therapies on rhinitis symptoms
15 GLOSSARY OF RHINITIS MEDICATIONS 15
GLOSSARY OF RHINITIS
MEDICATIONS
Name and
Also known as
Oral H1-
antihistamines
Local H1-
antihistamines
(Intranasal,
intraocular)
Intranasal
corticosteroids
Oral/ IM
corticosteroids
Generic name
2nd generation
Cetirizine
Ebastine
Fexofenadine
Loratadine
Mizolastine
Acrivastine
Azelastine
New products
Desloratadine
Levocetirizine
1st generation
Chlorpheniramine
Clemastine
Hydroxyzine
Ketotifen
Mequitazine
Oxatomide
O thers
Cardiotoxic
Astemizole
Terfenadine
Azelastine
Levocabastine
Beclomethasone
Budesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone
Dexamethasone
Hydrocortisone
Methylpredisolone
Prednisolone
Prednisone
Triamcinolone
Betamethasone
Deflazacort
Mechanism of
action
- blockage of H1
receptor
- some anti-allergic
activity
- new generation
drugs can be used
once daily
- no development
of tachyphylaxis
- blockage of H1
receptor
- some anti-allergic
activity for
azelastine
- reduce nasal
hyperreactivity
- potently reduce
nasal inflammation
- potently reduce
nasal inflammation
- reduce nasal
hyperreactivity
Side effects
2nd generation
- no sedation for
most drugs
- no anti-choliner-
gic effect
- no cardiotoxicity
- acrivastine has
sedative effects
- oral azelastine
may induce seda-
tion and a bitter
taste
1st generation
- sedation is
common
- and/ or anti-
cholinergic effect
- minor local side
effects
- azelastine: bitter
taste in some
patients
- minor local side
effects
- wide margin for
systemic side
effects
- growth concerns
with some mole-
cules only (see
p a ed i a tri c secti on
p . 2 0 )
- in young children
consider the combi-
nation of intranasal
and inhaled drugs
- systemic side
effects common in
particular for IM
drugs
- depot injections
may cause local
tissue atrophy
Comments
- new generation
oral H1- antihista-
mines are pre-
ferred for their
favourable
efficacy/ safety
ratio and
pharmacokinetics
- rapidly effective
(less than 1 hr) on
nasal and ocular
symptoms
- poorly effective
on nasal
congestion
- cardiotoxic drugs
should be avoided
-
rapidly effective
(<30mins) on nasal
or ocular symptoms
- the most effective
pharmacological
treatment of
allergic rhinitis
- effective on nasal
congestion
- effect on smell
- effect observed
after 6-12 hrs but
maximal effect
after a few days
- when possible,
intranasal corticos-
teroids should
replace oral or IM
drugs
- however, a short
course of oral corti-
costeroids may be
needed with severe
symptoms
16 GLOSSARY OF RHINITIS MEDICATIONS
Name and
Also known as
Local
chromones
(intranasal,
intraocular)
Oral
decongestants
Intranasal
decongestants
Intranasal
anticholinergics
Anti-
leukotrienes
Generic name
Cromoglycate
Nedocromil
Ephedrine
Phenylephrine
Pseudoephedrine
O thers
Epinephrine
Naphtazoline
Oxymethazoline
Phenylephrine
Tetrahydrozoline
Xylometazoline
O thers
Ipratropium
Montelukast
Pranlukast
Zafirlukast
Mechanism of
action
- mechanism of
action poorly
known
- sympathomimetic
drug
- relieve symptoms
of nasal congestion
- sympathomimetic
drug
- relieve symptoms
of nasal congestion
- anticholinergic
block almost exclu-
sively rhinorrhea
- block CystLT
receptor
Side effects
- minor local side
effects
- hypertension
- palpitations
- restlessness
- agitation
- tremor
- insomnia
- headache
- dry mucous
membranes
- urinary retention
- exacerbation of
glaucoma or
thyrotoxicosis
- same side effects
as oral
decongestants but
less intense
- rhinitis
medicamentosa (a
rebound phenome-
non occurring with
prolonged use over
10 days)
- minor local side
effects
- almost no sys-
temic anticholiner-
gic activity
- well tolerated
Comments
- intraocular
chromones are
very effective
- intranasal
chromones are less
effective and their
effect is short
lasting
- overall excellent
safety
- use oral
decongestants with
caution in patients
with heart disease
- Oral H1 -
antihistamine-
decongestant
combination
products may be
more effective than
either product
alone but side
effects are
combined
- act more rapidly
and more
effectively than oral
decongestants
- limit duration of
treatment to less
than 10 days to
avoid rhinitis
medicamentosa
- effective in
allergic and
non-allergic
patients with
rhinorrhea
- promising drugs
used alone or in
combination with
oral H1-antihista-
mines but more
data are needed to
position these
drugs
CONSIDER IMMUNOTHERAPY 17
CONSIDER
IMMUNOTHERAPY
Specific immunotherapy is effective when optimally administered.
Standardised therapeutic vaccines are favoured when available.
Subcutaneous immunotherapy raises contrasting efficacy and safety issues.
Thus, the use of optimal doses of vaccines labelled either in biological units
or in mass of major allergens has been proposed. Doses of 5 to 20 g of
the major allergen are optimal doses for most allergen vaccines.
Subcutaneous immunotherapy alters the natural course of allergic diseases.
Subcutaneous immunotherapy should be performed by trained personnel and
patients should be monitored for 20 minutes after injection.
Subcutaneous specific immunotherapy is indicated
In patients insufficiently controlled by conventional pharmacotherapy.
In patients in whom oral H1-antihistamines and intranasal pharmacotherapy
insufficiently control symptoms.
In patients who do not wish to be on pharmacotherapy.
In patients in whom pharmacotherapy produces undesirable side effects.
In patients who do not want to receive long-term pharmacological treatment.
High dose nasal and sublingual-swallow specific
immunotherapy
May be used with doses at least 50 to 100 times greater than those used for
subcutaneous immunotherapy.
In patients who had side effects or refused subcutaneous immunotherapy.
The indications follow those of subcutaneous injections.
In children, specific immunotherapy is effective. However, it is not
recommended to commence immunotherapy in children under 5 years of age.
TREAT IN A STEPWISE
APPROACH
(adolescents and adults)
18 TREAT IN A STEPWISE APPROACH
moderate mild
severe
Not in preferred order
oral H1 blocker
intranasal H1 - blocker
and/or decongestant
intranasal CS
(chromone)
in persistent rhinitis
review the patient
after 2-4 weeks
if failure: step-up
if improved; continue
for 1 month
Diagnosis of allergic rhinitis
(history skin prick tests or serum specific IgE)
Allergen avoidance
Intermittent symptoms Persistent symptoms
mild
Not in preferred order
oral H1 - blocker
intranasal H1 blocker
and/or decongestant
moderate
severe
intranasal CS
review the
after 2-4 wks
improved failure
review diagnosis
step-down review compliance
and continue query infections
treatment or other causes
for 1 month
increase rhinorrhea
intranasal CS add ipratropium
dose itch/sneeze blockage
add H1 blocker add
decongestant
or oral CS
(short term)
failure
surgical referral
If conjunctivitis add:
oral H1-blocker
or intraocular H1 blocker
or intraocular chromone
(or saline)
consider specific immunotherapy
review the patient
after 2-4 wks
improved failure
failure
review diagnosis
review compliance
query infections
or other causes
in persistent rhinitis
review the patient
after 2-4 weeks
In case of improvement: step down. In case of worsening: step up.
19 CONCOMITANT TREATMENT 19
Treatment of concomitant rhinitis
and asthma
The treatment of asthma should follow
the GINA guidelines.
Some of the drugs are effective in the treatment of both rhinitis
and asthma (e.g. glucocorticosteroids and antileukotrienes).
However, others are only effective in the treatment of either
rhinitis or asthma (e.g. - and -adrenergic agonists,
respectively).
Some drugs are more effective in rhinitis than in asthma
(e.g. H1-antihistamines).
Optimal management of rhinitis may improve coexisting
asthma.
Drugs administered by oral route may affect both nasal and
bronchial symptoms.
The safety of intranasal glucocorticosteroids is well estab-
lished. However, large doses of inhaled (intrabronchial)
glucocorticosteroids can induce side effects. One of the
problems of dual administration is the possibility of additive
side effects.
It has been proposed that the prevention or early treatment
of allergic rhinitis may help to prevent the occurrence of
asthma or the severity of bronchial symptoms but, more
data are needed.
20 PAEDIATRIC ASPECTS
PAEDIATRIC ASPECTS
Allergic rhinitis is part of the "allergic march" during childhood. Intermittent
allergic rhinitis is unusual before two years of age. Allergic rhinitis is most
prevalent during school age years.
Allergy tests can be done at any age and may yield important information.
The principles of treatment for children are the same as for adults, but special
care has to be taken to avoid the side effects typical in this age group.
Doses of medication have to be adjusted and special considerations followed.
Few medications have been tested in children under the age of two years.
In children, symptoms of allergic rhinitis can impair cognitive functioning and
school performance, which can be further impaired by the use of sedating
oral H1-antihistamines.
Oral and intramuscular glucocorticosteroids should be avoided in the
treatment of rhinitis in young children.
Intranasal glucocorticosteroids are an effective treatment for allergic rhinitis.
However, their possible effect on growth for some, but not all, intranasal
glucocorticosteroids is of concern. It has been shown that the recommended
doses of intranasal mometasone and fluticasone did not affect growth in
children with allergic rhinoconjunctivitis.
Disodium cromoglycate is commonly used to treat allergic rhinoconjunctivitis
in children because of the safety of the drug.
SPECIAL CONSIDERATIONS 21
SPECIAL
CONSIDERATIONS
Pregnancy
Rhinitis is often a problem during pregnancy since nasal obstruction may be
aggravated by the pregnancy itself.
Caution must be taken when administering any medication during pregnancy,
as most medications cross the placenta.
For most drugs, limited studies have been completed, and only on small
groups with no long-term analysis.
Ageing
With ageing, various physiological changes occur in the connective tissue
and vasculature of the nose which may predispose or contribute to chronic
rhinitis.
Allergy is a less common cause of persistent rhinitis in subjects over 65 years
of age.
atrophic rhinitis is common and difficult to control
rhinorrhea can be controlled with anticholinergics
some drugs (reserpine, guanethidine, phentolamine, methyldopa, prazosin,
chlorpromazine or ACE inhibitors) can cause rhinitis
Some drugs may induce specific side effects in elderly patients
decongestants and drugs with anticholinergic activity may cause urinary
retention in patients with prostatic hypertrophy
sedative drugs may have greater side effects
22 ADAPTING GUIDELINES FOR USE IN LOW INCOME COUNTRIES
ADAPTING GUIDELINES
FOR USE IN LOW
INCOME COUNTRIES
In developing countries, the management of rhinitis is based on medication
affordability and availability.
The rationale for treatment choice in developing countries is based upon:
level of efficacy
low drug cost affordable for the majority of patients
inclusion in the WHO essential list of drugs. (Only chlorpheniramine and
beclomethasone are listed.)
it is hoped that new drugs will shortly be included on this list
Immunotherapy is not usually recommended in developing countries for the
following reasons:
many allergens in developing countries are not well identified
specialists must prescribe desensitisation
Stepwise treatment proposed:
Mi ld i nter mi ttent r hi ni ti s: oral H1-antihistamines.
Moder ate-Sever e i nter mi ttent r hi ni ti s: Intranasal beclomethasone
(300-400g daily). If needed, after a week of treatment, oral
H1-antihistamines and/ or a short term course of oral corticosteroids will
be added.
Mi ld per si stent r hi ni ti s: Treatment with oral H1-antihistamines or a low dose
(100-200 g) of intranasal beclomethasone will be sufficient.
Moder ate-Sever e per si stent r hi ni ti s: Intranasal beclomethasone (300-400 g
daily). If symptoms are severe, add oral H1-antihistamines and/ or a short
course of oral corticosteroids at the beginning of the treatment.
Asthma management for developing countries is included in the
IUATLD Asthma Guide. The affordability of inhaled steroids is usually low in
developing countries. If the patient can afford to be treated for both
manifestations of the disease, it is recommended to add the treatment of
allergic rhinitis to the asthma management plan.
23 ADAPTING GUIDELINES FOR LOCAL USE 23
ADAPTING GUIDELINES
FOR LOCAL USE
Local resources and cultural preferences determine how guidelines are used in each
community and must be considered as you:
estimate the prevalence and costs of allergic rhinitis
make prescribing decisions based on drug affordability and availability
24

NOTES
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